Prevalence of Parent-Reported Traumatic Brain Injury in Children and Associated Health Conditions

Key Points

Question

What are the national and state estimates of parent-reported, diagnosed traumatic brain injury in children aged 0 to 17 years?

Findings

In this analysis of data from the National Survey of Children’s Health, children were shown to have a lifetime estimate of a parent-reported traumatic brain injury diagnosis of 2.5%. National estimates of the association between traumatic brain injury and other childhood health conditions is reported along with parent report of insurance coverage and perception of insurance adequacy.

Meaning

A large number of children experience traumatic brain injury in the United States, and these children are more likely to have childhood health conditions; insurance type and parent adequacy perception contribute to care seeking and outcomes for children.

Abstract

Importance

Traumatic brain injury (TBI) in children results in a high number of emergency department visits and risk for long-term adverse effects.

Objectives

To estimate lifetime prevalence of TBI in a nationally representative sample of US children and describe the association between TBI and other childhood health conditions.

Design, Setting, and Participants

Data were analyzed from the 2011-2012 National Survey of Children’s Health, a cross-sectional telephone survey of US households with a response rate of 23%. Traumatic brain injury prevalence estimates were stratified by sociodemographic characteristics. The likelihood of reporting specific health conditions was compared between children with and without TBI. Age-adjusted prevalence estimates were computed for each state. Associations between TBI prevalence, insurance type, and parent rating of insurance adequacy were examined. Data analysis was conducted from February 1, 2016, through November 1, 2017.

Main Outcomes and Measures

Lifetime estimate of TBI in children, associated childhood health conditions, and parent report of health insurance type and adequacy.

Results

The lifetime estimate of parent-reported TBI among children was 2.5% (95% CI, 2.3%-2.7%), representing over 1.8 million children nationally. Children with a lifetime history of TBI were more likely to have a variety of health conditions compared with those without a TBI history. Those with the highest prevalence included learning disorders (21.4%; 95% CI, 18.1%-25.2%); attention-deficit/hyperactivity disorder (20.5%; 95% CI, 17.4%-24.0%); speech/language problems (18.6%; 95% CI, 15.8%-21.7%); developmental delay (15.3%; 95% CI, 12.9%-18.1%); bone, joint, or muscle problems (14.2%; 95% CI, 11.6%-17.2%); and anxiety problems (13.2%; 95% CI, 11.0%-16.0%). States with a higher prevalence of childhood TBI were more likely to have a higher proportion of children with private health insurance and higher parent report of adequate insurance. Examples of states with higher prevalence of TBI and higher proportion of private insurance included Maine, Vermont, Pennsylvania, Washington, Montana, Wyoming North Dakota, South Dakota, and Colorado.

Conclusions and Relevance

A large number of US children have experienced a TBI during childhood. Higher TBI prevalence in states with greater levels of private insurance and insurance adequacy may suggest an underrecognition of TBI among children with less access to care. For more comprehensive monitoring, health care professionals should be aware of the increased risk of associated health conditions among children with TBI.

This population-based survey by the Centers for Disease Control and Prevention examines the prevalence of traumatic brain injury in children throughout the United States.

Introduction

Traumatic brain injury (TBI) in children has a relatively high rate of emergency department (ED) visits¹ and risk for long-term adverse effects,^2,3,4,5 creating a large public health concern. Traumatic brain injury in children can alter cognitive, language, and behavioral development, which can affect learning at school,⁶ and has also been linked to other comorbid health conditions, such as neurologic disorders (eg, motor difficulties and epilepsy), attention-deficit/hyperactivity disorder (ADHD), mental disorders, and sleep disorders.⁷ These conditions can further affect social and emotional development. In 2013, there were approximately 640 000 TBI-related ED visits, 18 000 TBI-related hospitalizations, and 1500 TBI-related deaths among children aged 14 years and younger.¹ Children aged 0 to 4 years had the highest rates of TBI-related ED visits of any age group except those older than 75 years.¹ The leading causes of TBI-related ED visits, hospitalizations, and deaths for individuals aged 0 to 14 years were unintentional falls and being struck by or against an object, whereas for those aged 15 to 24 years, the leading causes were motor vehicle crashes and falls.¹ Another common cause of TBI is sports and recreational activity, which accounted for an estimated 325 000 TBI ED visits among children and adolescents in 2012.⁸

Mild TBI, a brief change in mental status or consciousness that is commonly called concussion,⁹ accounts for 70% to 90% of TBI ED visits.^10,11 Children with mild TBI or concussions may seek care at clinical locations other than the ED or may not seek care, making it difficult to accurately estimate the true incidence, which is a critical factor for understanding the total public health outcome of TBI in children.^10,12,13 More recent research examining point of entry for an initial visit for concussion care found that in a large, urban, pediatric health care system, 48.8% of children with TBI visited primary care; 27.2%, specialty care; and 20.2%, ED care.¹⁴ Because most pediatric TBIs are mild, only a fraction of children seen for emergency medical care for a TBI are hospitalized—a metric that has been used as an indicator of injury severity.¹⁵ In a cohort study reporting severity in children seeking emergency medical care from hospitals (N = 2940), 84.5% had mild TBI, 13.2% had moderate TBI, and 2.3% had severe TBI.¹⁶ Traumatic brain injury hospitalizations for children have decreased in recent years.¹ Because most incidence reports of mild TBI are based on ED care, current estimates may be underestimating the outcome of pediatric TBI.

Traumatic brain injury in children has been linked to other childhood health conditions, including ADHD,^17,18,19,20 seizures,^21,22 behavior problems,^23,24,25,26 mental disorders,²⁷ learning problems,^2,23,28 and hearing problems.^29,30 Furthermore, children who have sustained a TBI tend to use speech and language services after their injury, indicating concerns about acquired cognitive and communication disorders.^4,31 There are a number of health outcomes associated with TBI in children, supporting the need for more detailed estimates of conditions associated with TBI.

We currently have an understanding of the incidence of TBI from estimates of TBI-related ED visits and hospitalizations among children. However, these data do not allow for estimates of the number of children seen in other clinical settings or those who do not receive care and provide limited data on comorbid health conditions. The purpose of this study was to estimate both the national and state-specific prevalence of lifetime TBI based on parents’ report of a health care professional diagnosis of brain injury or concussion. Additional aims were to describe the association between TBI and other health conditions in this population and examine associations between state-level prevalence of TBI and state-level insurance coverage.

Methods

Participant Sample

Data were analyzed from the 2011-2012 National Survey of Children’s Health³² (NSCH), conducted by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC) as a module of the State and Local Area Integrated Telephone Survey, to determine a lifetime TBI history. Data analysis was conducted from February 1, 2016, through November 1, 2017. The NCHS Research Ethics Review Board and the institutional review board of NORC at the University of Chicago approved all study procedures and modifications. Participants provided verbal informed consent.

The NSCH is a cross-sectional telephone survey of US households using a random digit dial sample of landlines and cell phones designed to allow for both national and state estimates of children’s health.³³ A parent or guardian answered questions in relation to 1 randomly selected child (N = 95 677) aged 0 through 17 years. The interview completion rate (the proportion of households who completed the interview among households known to include children) was 54.1% (landline) and 41.2% (cell phone). The overall response rate—including all nonresponses, such as households that were never successfully screened for the presence of children and telephone lines that rang with no answer—was 23.0%.

For these analyses, TBI was defined by a positive response to the question: “Has a doctor or other health care provider ever told you that [your child] had…a brain injury or concussion?” A help screen was provided for the interviewer that further defined a concussion and indicated that developmental conditions, such as autism, cerebral palsy, or brain tumors, should not be considered as brain injuries. Questions framed in a similar manner were asked for other health conditions, for example, ADHD, hearing problems, anxiety and behavioral or conduct problems, and epilepsy or a seizure disorder, to indicate a child’s lifetime history of the specific condition. The household respondent also reported sociodemographic characteristics including the child’s sex, age, race, Hispanic ethnicity, household income (later categorized to reflect the federal poverty level), health insurance status (private, public, or uninsured), and highest educational level achieved by the parent/adult respondent living with the child. Within the survey, parents were asked questions related to whether their child had health insurance, the type of insurance, and their perception of the adequacy of their child’s current health insurance. Data are weighted to represent all noninstitutionalized children living in the United States.

Statistical Analysis

The weighted prevalence of a lifetime history of TBI was calculated by using SUDAAN’s crosstab procedure with 95% CIs derived from Taylor linearization. In addition, prevalence estimates were stratified by sociodemographic characteristics. Differences in TBI prevalence estimates by sociodemographic group were tested using the Wald F test. We also examined the trend in TBI prevalence by age using the stratum-adjusted Cochran-Mantel-Haenszel trend test (Wald χ² = 257.2490, P < .001).

Crude TBI prevalence rate ratios were estimated by using logistic regression. To examine the association between TBI and specific health conditions, the prevalence of each health condition was calculated among children with and without TBI; prevalence rate ratios were adjusted by age, sex, race/ethnicity, and household income in logistic regression models. To reduce the outcome of different age distributions, age-adjusted lifetime TBI prevalence estimates were computed for each state. Logistic regression models were used to compute the odds ratios (ORs) for the associations between TBI prevalence by state with private health insurance type and with parent report of health care adequacy separately. In the logistic regression models, TBI prevalence rates were grouped hierarchically in 4 groups, and an individual’s private insurance type (private insurance type, 1/0) or report of adequate insurance (insurance adequate, 1/0) was modeled as an outcome variable as a function of state TBI prevalence (the lowest TBI category was used as the reference level).

The relative SE, a measure of an estimate’s statistical reliability (100 times SE of an estimate divided by the estimate), was calculated for each estimate and cell sizes reviewed. All relative SEs were less than 30%, and all sample sizes were greater than 20. SAS, version 9.3 (SAS Institute Inc) and SAS-callable SUDAAN, version 11.0 (Research Triangle Institute) were used for statistical analysis. All analyses were performed by incorporating complex sample design features (including stratified sampling and weighting for unequal sample selection probabilities and nonresponse). Statistical significance of all 2-sided, unpaired P values was set at .05.

Results

Prevalence of TBI in Children

Among US children aged 0 to 17 years, the lifetime estimate of a parent-reported TBI diagnosis (ie, ever being told by a health care professional that the child had a brain injury or concussion) was 2.5% (95% CI, 2.3%-2.7%); this figure represents over 1.8 million US children (Table 1). Parent report of TBI in this survey was more common among children who were non-Hispanic white, boys, and those with private health insurance (Table 1). A trend test showed that TBI prevalence (percentage) increased with increasing age: 0 to 4 years (0.6%; 95% CI, 0.5%-1.0%), 5 to 11 years (1.7; 95% CI, 1.4%-2.0%), 12 to 14 years (3.9; 95% CI, 3.3%-4.5%), and 15 to 17 years (5.9; 95% CI, 5.3%-6.6%) (P < .01).

Table 1. Characteristics of Children With Parent Report of Brain Injury or Concussion^a.

Characteristic	No. of TBIs in Sample (Unweighted)	Estimated Population With TBI (Weighted)	TBI Prevalence (Weighted), % (95% CI)	Adjusted Prevalence Ratio (Weighted) (95% CI)
Overall	2871	1 850 000	2.5 (2.3-2.7)
Children
Age, yb
0-4	195	128 000	0.6 (0.5-1.0)	1 [Reference]
5-11	703	490 000	1.7 (1.4-2.0)	2.7 (1.8- 3.9)
12-14	656	479 000	3.9 (3.3-4.5)	6.1 (4.2- 8.7)
15-17	1317	753 000	5.9 (5.3-6.6)	9.2 (6.4-13.1)
Sex
Male	1793	1 148 000	3.1 (2.8-3.4)	1.6 (1.3-1.9)
Female	1075	700 000	2.0 (1.7-2.3)	1 [Reference]
Missing/other	3
Race/ethnicity
Hispanic	225	266 000	1.6 (1.1-2.2)	0.5 (0.3-0.7)
White, non-Hispanic	2195	1 234 000	3.3 (3.0-3.6)	1 [Reference]
Black, non-Hispanic	119	134000	1.4 (1.0-2.0)	0.4 (0.3-0.6)
Multiracial/other, non-Hispanic	279	179 000	2.4 (1.9-3.1)	0.5 (0.3-0.9)
Missing	53
Household
Parent educational level
<High school or high school	1282	946 000	2.6 (2.3-3.0)	1 [Reference]
>High school	1472	825 000	2.6 (2.3-2.9)	1.0 (0.8-1.2)
Missing/DK/other	117
Family structure
2 Parent, biological or adopted	1894	1 126 000	2.4 (2.1-2.6)	1 [Reference]
2 Parent, step family	257	203 000	3.2 (2.5-4.1)	1.4 (1.0-1.8)
Single mother, no father present	507	365 000	2.7 (2.2-3.1)	1.1 (0.9-1.4)
Other	192	141 000	2.9 (2.0-4.1)	1.2 (0.9-1.8)
Household income, FPL %c
<100	338	276 000	1.7 (1.3-2.1)	1 [Reference]
100-199	479	311 000	2.0 (1.6-2.4)	1.2 (0.9-1.6)
200-399	870	575 000	2.8 (2.4-3.2)	1.7 (1.3-2.2)
≥400	1184	688 000	3.4 (3.0-3.8)	2.1 (1.5-2.6)
Health insurancec
Enrolled in health insuranced	2774	1 783 000	2.6 (2.4-2.8)	1.6 (1.1-2.4)
Lapse of insurancee	92	65 000	1.6 (1.1-2.4)	1 [Reference]
Missing/other	5
Insurance adequacy
Yes	1970	1 303 000	2.5 (2.2-2.7)	0.9 (0.8-1.1)
No	901	546 000	2.6 (2.3-3.0)	1 [Reference]
Type of insurancec
Public (Medicaid/SCHIP)	756	567 000	2.1 (1.8-2.5)	1 [Reference]
Private	2007	1 210 000	2.9 (2.7-3.2)	1.4 (1.1-1.7)
Uninsured/missing/other	108

Abbreviations: DK, do not know; FPL, federal poverty level; SCHIP, State Children's Health Insurance Program; TBI, traumatic brain injury (parent report of diagnosed brain injury or concussion).

^aData source: 2011-2012 National Survey of Children’s Health.

^bTBI age trend test results obtained by using the stratum-adjusted Cochran-Mantel-Haenszel hypothesis test, Wald χ² = 257.2490, P < .001.

^cPopulation prevalence estimates rounded to the nearest thousand.

^dEnrolled in any type of health insurance (private or public).

^eLapse in health insurance reported at the time of interview.

TBI and Childhood Health Conditions

After adjustment for sociodemographic characteristics of age, sex, parent educational level, and household income, children with a lifetime history of TBI were more likely to have received a parent-reported diagnosis of 13 of the 14 health conditions examined compared with children without a history of TBI (Table 2). For example, prevalence ratios ranged from 1.6 for ADHD to 7.3 for epilepsy or seizure disorder. Additional mental disorders (depression, anxiety problems, or behavioral and conduct problems), neurologic conditions (Tourette syndrome, epilepsy), chronic health conditions (hearing, vision), and intellectual disability were also significantly more likely to be reported by parents of children with a history of TBI. The conditions most commonly reported among children with a history of TBI were learning disorders (21%), ADHD (20%), speech and language problems (19%), developmental delay (15%), and bone, joint, or muscle problems (14%). Although learning disorders, ADHD, and speech and language problems were also the conditions most commonly reported by parents of children without a history of TBI, their prevalence was lower than in the TBI group.

Table 2. Prevalence of Parent-Reported Health Conditions Among Children With and Without a Parent-Reported, Diagnosed Brain Injury or Concussion^a.

Health Condition	Presence of Specific Health Condition, Prevalence (95% CI)		Adjusted Prevalence Ratio (95% CI)b
	TBI	No TBI
Epilepsy or seizure disorder	7.9 (5.8-10.7)	1.0 (0.9-1.1)	7.3 (5.0-10.5)
Intellectual disability	5.9 (4.5-7.7)	1.0 (0.8-1.1)	5.1 (3.7-7.0)
Bone, joint, or muscle problem	14.2 (11.6-17.2)	2.8 (2.6-3.1)	3.7 (3.0-4.7)
Vision problem	6.7 (4.8-9.4)	1.6 (1.4-1.8)	3.6 (2.5-5.1)
Developmental delay	15.3 (12.9-18.1)	4.9 (4.6-5.2)	2.9 (2.4-3.4)
Speech/language problem	18.6 (15.8-21.7)	7.9 (7.5-8.3)	2.2 (1.7-2.6)
Tourette syndrome	0.8 (0.4-1.7)	0.2 (0.1-0.2)	2.2 (1.0-4.6)
Behavioral or conduct problems	9.3 (7.0-12.1)	3.5 (3.3-3.8)	2.1 (1.5-2.8)
Depression	10.9 (8.7-13.5)	3.2 (2.9-3.5)	2.1 (1.7-2.7)
Anxiety problem	13.2 (11.0-16.0)	4.3 (4.1-4.6)	2.0 (1.6-2.4)
Autism spectrum disorder	5.1 (3.7-6.9)	2.0 (1.8-2.2)	1.9 (1.4-2.8)
Learning disorder	21.4 (18.1-25.2)	8.6 (8.2-9.0)	1.9 (1.6-2.3)
ADHD	20.5 (17.4-24.0)	8.5 (8.1-8.9)	1.6 (1.4-1.9)
Diabetes	0.6 (0.4-1.0)	0.4 (0.3-0.5)	1.0 (0.6-1.7)

Abbreviations: ADHD, attention-deficit/hyperactivity disorder; TBI, traumatic brain injury (parent report of diagnosed brain injury or concussion).

^aData source: 2011-2012 National Survey of Children’s Health.

^bPrevalence of specific condition among children with vs without brain injury, adjusted by age, sex, race/ethnicity, and household income.

Lifetime History of TBI by State

State estimates of parent-reported TBI ranged from an age-adjusted prevalence of 1.20% in Mississippi to 5.30% in Maine (Table 3, Figure 1). In examining health insurance type, states with a higher prevalence of childhood TBI were more likely to also have higher estimates of private health insurance compared with public health insurance (OR, 1.36; 95% CI, 1.27-1.46). Examples of states with higher proportions of private insurance include Maine, Vermont, Pennsylvania, Washington, Montana, Wyoming, North Dakota, South Dakota, Colorado, and Michigan. States with a higher prevalence of childhood TBI also had higher estimates of parent-reported adequate insurance compared with those reporting less-adequate insurance (OR, 1.18; 95% CI, 1.16-1.36) (Figure 2).

Table 3. Age-Adjusted Prevalence of Parent-Reported, Diagnosed Brain Injury or Concussion (TBI) Among Children by State^a.

State	No. of TBIs in Sample (Unweighted)	Estimated Population With TBI (Weighted)	Age-Adjusted Prevalence (95% CI)
Total	2871	1 849 989	2.51 (2.32-2.72)
Alabama	47	19 500	1.72 (1.15-2.57)
Alaska	51	5600	3.14 (2.14-4.60)
Arizona	53	40 574	2.50 (1.67-3.75)
Arkansas	41	12 178	1.73 (1.09-2.72)
California	36	176 924	1.91 (1.17-3.10)
Colorado	84	50 731	4.26 (3.15-5.73)
Connecticut	76	25 663	3.01 (2.28-3.96)
Delaware	41	3482	1.74 (1.13-2.69)
District of Columbia	41	2692	2.77 (1.66-4.60)
Florida	35	55 233	1.38 (0.82-2.34)
Georgia	39	42 534	1.78 (1.16-2.71)
Hawaii	40	7463	2.47 (1.62-3.74)
Idaho	71	12 509	3.00 (2.06-4.34)
Illinois	62	99 952	3.21 (2.31-4.46)
Indiana	67	58 732	3.72 (2.64-5.22)
Iowa	52	17 422	2.40 (1.70-3.37)
Kansas	65	25 606	3.64 (2.57-5.14)
Kentucky	46	27 884	2.76 (1.93-3.93)
Louisiana	30	14 587	1.31 (0.74-2.29)
Maine	90	14 450	5.30 (4.06-6.88)
Maryland	56	30 308	2.24 (1.54-3.27)
Massachusetts	67	51 217	3.53 (2.64-4.71)
Michigan	35	32 598	1.37 (0.84-2.22)
Minnesota	67	41 081	3.32 (2.39-4.59)
Mississippi	33	9006	1.20 (0.69-2.07)
Missouri	58	38 007	2.66 (1.91-3.70)
Montana	80	9131	4.29 (3.16-5.79)
Nebraska	59	16 592	3.78 (2.74-5.20)
Nevada	43	10 695	1.68 (1.03-2.73)
New Hampshire	70	10 918	3.57 (2.66-4.78)
New Jersey	48	56 919	2.69 (1.83-3.93)
New Mexico	49	10 957	2.17 (1.40-3.37)
New York	48	103 776	2.40 (1.67-3.42)
North Carolina	55	52 386	2.33 (1.62-3.34)
North Dakota	64	5769	3.98 (2.84-5.56)
Ohio	63	96 961	3.52 (2.43-5.07)
Oklahoma	48	16 788	1.84 (1.27-2.66)
Oregon	71	35 148	4.16 (3.08-5.60)
Pennsylvania	86	142 760	5.01 (3.66-6.82)
Rhode Island	64	7686	3.42 (2.41-4.82)
South Carolina	34	16 825	1.57 (0.98-2.50)
South Dakota	61	8333	4.30 (3.13-5.88)
Tennessee	46	37 845	2.53 (1.69-3.77)
Texas	35	92 715	1.38 (0.77-2.47)
Utah	64	21 943	2.66 (1.92-3.68)
Vermont	89	5940	4.41 (3.35-5.77)
Virginia	41	37 444	2.00 (1.28-3.10)
Washington	77	52 123	3.38 (2.41-4.71)
West Virginia	50	12 131	3.15 (2.21-4.45)
Wisconsin	69	66 652	5.03 (3.67-6.87)
Wyoming	74	5598	4.20 (3.08-5.69)

^aData source: 2011-2012 National Survey of Children’s Health.

Figure 1. Age-Adjusted Prevalence of Parent-Reported, Diagnosed Brain Injury or Concussion Among Children, by State.

TBI indicates parent report of diagnosed traumatic brain injury or concussion.

Figure 2. Association of Private Insurance and Parent Report of Insurance Adequacy With State-Level Prevalence Estimates of Parent-Reported, Diagnosed Brain Injury or Concussion by Prevalence Group.

Parent report of diagnosed traumatic brain injury or concussion; 1.2%-1.9% was established as a reference group, with an odds ratio of 1.0.

Discussion

Based on parent report of a health care professional’s diagnosis among a nationally representative sample in 2011-2012, 2.5% of US children aged 0 to 17 years have experienced a TBI in their lifetime. To our knowledge, this is the first lifetime estimate across the developmental age span for children. Previous national estimates were based on ED visit rates or a report of visit location for concussion in a large pediatric health care system.¹⁴ In 2013, children aged 0 to 4 years (1591 per 100 000 population) had the highest rate of pediatric ED visits followed by children in the age 15- to 24-year population (1080.7 per 100 000 population).¹

The estimate provided by this study does not capture children who did not receive medical care for their injury, so it is likely an underestimate of childhood TBI in the United States. In addition, the type of clinician and the location of the health care visit where the TBI was diagnosed was not included as part of the survey. Consequently, this study cannot provide information on where parents sought treatment for a TBI sustained by their children.

Findings from this nationally representative sample indicate a higher occurrence of other health and developmental conditions in children who experienced a lifetime TBI, including learning disorders, ADHD, speech and language problems, developmental delay, anxiety, depression, and behavior problems. Although many of these findings align with previous research reporting on the association of TBI with other childhood health conditions,^{3,17,18,19,20,21,22,23,24,25,26,34} to our knowledge, this is the first report to examine associations in a national sample and include speech and language conditions and developmental delay. Previous reports have provided prevalence data on these specific conditions but have not considered an association with TBI. The presence of these conditions may be a compounding factor affecting the likelihood of experiencing cognitive, social, and health challenges following TBI. However, due to the cross-sectional nature of the NSCH, we cannot distinguish whether the conditions occurred before or after the TBI and therefore cannot determine whether these conditions contributed to or were a consequence of the TBI. Knowing the association of other childhood health conditions with TBI suggests that health care professionals should inquire about TBI history at the time of diagnosis of childhood health conditions and ask parents about a child’s total health history at the time of TBI diagnosis. Understanding a more comprehensive picture of a child’s health status at the time of TBI diagnosis facilitates optimal management to improve recovery and outcomes.

The map (Figure 1) illustrates differences in state estimates of the age-adjusted prevalence of parent-reported TBI diagnosed by a health care professional. Estimates of uninsured populations in 2011-2012 were previously reported by region rather than state, with higher estimates in the South (18.6%) and West (17.0%) compared with the Northeast (10.8%) and Midwest (11.9%).³⁵ Recent research indicates that insurance status among children with TBI is associated with better health outcomes. Children with TBI who had private health insurance had lower mortality rates and better quality of care following TBI than those with public insurance or those who were uninsured,³⁶ suggesting an association between insurance type and health care quality for children with TBI. In this study, individuals in states with higher levels of TBI were more likely to report private insurance and adequate insurance coverage, suggesting that insurance coverage may explain some of the differences in lifetime TBI estimates found between states.

Some studies of pediatric TBI report high rates of private insurance,¹⁴ suggesting that coverage by this insurance type may support seeking care at the time of the TBI. Also, parents who believe that they have adequate insurance may be willing to seek care. However, further investigation is needed to determine additional factors related to seeking care for TBI in children, including parents’ views on the need for a medical assessment of TBI.

Limitations

This study has limitations. The NSCH relies on parent report of health care professionals’ diagnosed brain injury or concussion, other health conditions and insurance, and does not examine medical records. Health care professionals’ diagnoses were inferred by parents’ response to survey questions; however, these estimates may have been affected by difficulties in recall as well as any challenges related to communication of the diagnosis between the health care professional and the parent/guardian. This survey did not capture those who experienced a TBI but did not seek a medical assessment by a health care professional. In addition, other types of acquired brain trauma, such as anoxic brain injuries (ie, due to lack of oxygen), may have been included in affirmative responses provided by respondents resulting from question wording (ie, a brain injury or concussion). The response rate for this survey was low, increasing the likelihood that the results were influenced by factors associated with the decision to participate. However, the data were weighted to adjust for nonresponse in an effort to account for differences between the sample and population.

The brain injury question includes help text informing parents not to consider developmental conditions, such as cerebral palsy and autism; however, it is possible that some parents missed that instruction and incorrectly included those conditions as brain injuries. To the extent that this misunderstanding occurred, it would increase the report of brain injuries and contribute to the observed association between autism and brain injury. Directionality between TBI and associated health conditions cannot be inferred owing to the cross-sectional nature of the study. Parent report of health insurance indicated current status, so it is possible that one’s insurance status was different at the time of the injury.

Conclusions

Children of all backgrounds may be affected by TBI in their lifetime, highlighting the importance of inquiring about a history of TBI during well-child health care visits. The combination of TBI and the health conditions associated with a TBI can have a significant outcome on a child’s overall health, learning, and behavior. Although it is unclear whether the conditions existed prior to or are a consequence of the TBI injury, improved care for children can be better achieved if pediatric health care professionals offer medical guidance to parents in the context of a child’s overall health history, including history of lifetime TBI. For children with diagnosed TBI, health care professionals can assess for conditions identified in this analysis. To produce more comprehensive estimates of TBI in children, nonmedical data sources will need to be expanded to capture children who do not or cannot seek treatment. A proposed system, the National Concussion Surveillance System, holds the potential for obtaining more comprehensive prevalence estimates of TBI in children.³⁷